Docstoc

Client Intake Form

Document Sample
Client Intake Form Powered By Docstoc
					Phone: (xxx) xxx-xxxx

COMPANY NAME Address City, State Zip www.yourwebsite.com

Fax: (xxx) xxx-xxxx

CLIENT INTAKE FORM
(Please Print) Today’s Date _____/_____/_____ Therapist______________________________
First If not, what is your legal name? Middle (Former Name) Marital Status (Circle One)

CLIENT INFORMATION
Client’s Last Name Is this your legal name?  Yes  No City City Employer  Dr.  Yellow Pages  Other Alternative Email Address: State ZIP Code State Social Security P.O. Box Occupation ZIP Code Street Address  Mr.  Ms. Single / Married / Other Birth Date Age Sex / / Home Phone No. ( ) Cell Phone No. ( ( Referred to Provider by (Please check one box & list)  Family  Friend  Close to Home/Work ) )  Website Work Phone No.  Insurance Plan M F

Email Address:

INSURANCE INFORMATION
Person Responsible for Bill Email Address: Occupation Employer Birth Date / /

(PLEASE GIVE YOUR INSURANCE CARD TO THE OFFICE MANAGER)
Address (if different) Home Phone No. ( ) Cell Phone No. ( ) Work Phone No. ( )

Employer Address

Is this client covered by insurance?

 Yes

 No

Is this an EAP visit?

 Yes

 No

Total Annual EAPs allowed? _______

 Amerigroup  Assurant  Beech Street Please Select Your Primary Insurance Provider

 Blue Cross/Blue Sheild  ChoiceCare  Champus

 Cigna  Definity Health  First Health  HealthSmart  Humana  Magellan/Aetna  Medicaid  Medicare  MHN/MHNet  PHCS  PMHS  Texas One Choice  TriCare  Unicare

 United Healthcare  Value Options
What is the authorization number? Insured’s Name Client’s Relationship to Insured Insured’s S.S. #  Self Birth Date /  Spouse Insured’s Name  Spouse  Child /  Child

 Other ____________________________________
 Self Pay Group #  Other Group #  Other Policy # Policy # Co-Payment $

Name of Secondary Insurance (if any) annnanapplicable) Client’s Relationship to Insured  Self

IN CASE OF EMERGENCY
Name of Local Friend or Relative (not living at same address) Relationship to Client Home Phone No. Work Phone No.

Your Company CLIENT INTAKE FORM
(Continuation)

PLEASE READ THE FOLLOWING CAREFULLY I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. ____________________________ will honor contractual agreements made with those managed health care companies which stipulate specific reimbursement restrictions.

X CLIENT/GUARDIAN SIGNATURE DATE

I hereby consent to treatment by specified provider. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have a right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.
X CLIENT/GUARDIAN SIGNATURE DATE

I hereby authorize the release of necessary medical information for insurance reimbursement purposes.
X CLIENT/GUARDIAN SIGNATURE DATE

I authorize the payment of medical benefits to the provider of services.
X CLIENT/GUARDIAN SIGNATURE DATE


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:66
posted:5/25/2009
language:English
pages:2